Post Traumatic Headache...2018/07/05 · Phenotype of Headache following TBI (N=378) 38% 25% 21%...

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Post Traumatic Headache

Content developed by:

Tad Seifert, MDDonna Gutterman, PharmD

Faculty Disclosures

TAD SEIFERT, MD

Dr. Seifert has nothing to disclose.

DONNA GUTTERMAN, PHARMD

Dr. Gutterman has received consulting fees and/or honoraria fromNuPathe, Teva Pharmaceuticals, Dr. Reddy Pharmaceuticals.

Learning Objectives

At the conclusion of this presentation, participants should be able to:

• List the defining features of posttraumatic headache

• Develop treatment plans for patients in the acute/subacute stage of injury and with chronic postconcussive headache

• Describe the key components of concussion management in the Zurich statement

• Individualize Return To Play decisions

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PTH in Civilians

Posttraumatic Headache

Up to 90% of individuals sustaining mTBI1

Most common symptom after minor head trauma

Occurs in ≈94% of athletes with sports-related concussion2

1. Kirk C et al. Dev Med Child Neurol. 2008;;50(6):422–425.; 2. Marar M et al. Am J Sports Med. 2012; 40:747–755.

Posttraumatic Headache in ICHD-3

5.1.2 Acute post-traumatic

headache attributed to mild traumatic injury to the head

Headache develops ≤7 days

of trauma

5.1.2.1 Delayed-onset acute


Interval between injury and

headache onset is >7 days

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Posttraumatic Headache in ICHD-3 cont.

5.1.2 Acute post-traumatic


Headache develops ≤7 days

of trauma

5.1.2.1 Delayed-onset acute


Interval between injury and

headache onset is >7 days

5.2 Persistent headache attributed to traumatic injury to the head*

Headache >3 months caused by traumatic injury to the head

*Coded as “chronic post-traumatic headache” in ICHD-II.

Characteristics of Posttraumatic Headache

Phenotype of Headache following TBI (N=378)

38%

25%

21%

10%

6%

Lucas S et al. Cephalalgia. 2012;32:600–606.

CervicogenicMigraine Probable migraine

Tension-type Other

Posttraumatic Headache Treatment

Treated as the primary headache disorder it most closely resembles

• Acute treatment

• Preventive treatment

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Treatment Studies in TBI

Study TBI Severity Intervention Outcome

Friedman et al Mixed* Ketoprofen Decreased HA burden

Gawel et al Not specified Sumatriptan Decreased Frontal Sx

Packard Mild Valproic Acid 44% improved 25-50%

Saran Mild Amitriptyline No improvement

Hecht Mixed* 5% bupivicaine blocks 80% complete relief

Lay and Newman Mild Indomethacin HA improved

McBeath and Nanda Not specifiedIV ergotamine + metoclopramide

85% good/excellentresponse

Weiss et al MildPropranolol and/or amitriptyline

21/30 w/reduced HA frequency

Matharu and Goadsby Mild Indomethacin HA resolution

Wright Mild Amitriptyline HA improvement

*Some mTBI

PTH Treatment

Nonpharmacologic

• Therapeutic massage and physical therapy

• Cognitive behavioral therapy

• Education regarding overuse of acute medications

PTH Treatment

Nonpharmacologic

• Therapeutic massage and physical therapy

• Cognitive behavioral therapy

• Education regarding overuse of acute medications

Pharmacologic

• Nerve blocks

• OnabotulinumtoxinA

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Risk Factors for Persistent PTH

Personal history of headache



Family history of headache




Female gender

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Female gender

Chronic pain prior to injury




Female gender


Symptoms of depression




Female gender



Low socioeconomic status

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Inversely related to severity of trauma



Female gender



Low socioeconomic status

PTH in CiviliansPTH in Military Personnel

Prevalence of Military TBI

• 2.6 million returning veterans

• Up to 20% have a TBI1

• 33% meet criteria for chronic PTH2

Elder GA et al. Mt Sinai J Med. 2009;76:111–118; Theeler BJ et al. Headache. 2010;50:1262–1272.

≈173,000 with chronic PTH

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Causes of Military TBI

Defense and Veterans Brain Injury Center; data through 31 October 2008.

54%

27%

6%

6%

4%

Blast

Multiple

Vehicular

Falls

Other

Bullet (2%)

Fragment (1%)

PTH in the Military

Only 18.7% of those with persistent PTH return to combat

Cohen SP et al. Cephalalgia. 2012;32:94–108.

Negative predictors

• Smoking

• Psychiatric comorbidities

• Male sex

• Enlisted rank

Comorbid Conditions Common in Soldiers With Persistent PTH

Persistent

PTH

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Persistent

PTH

PTSD


Persistent

PTH

PTSD

Substance abuse


Persistent

PTH

PTSD

Nightmares Substance abuse

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Persistent

PTH

PTSD

Insomnia

Nightmares Substance abuse


Persistent

PTH

PTSD

Insomnia

Nightmares

Memory complaints

Substance abuse


Persistent

PTH

PTSD Depression

Insomnia

Nightmares

Memory complaints

Substance abuse

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Managing Persistent PTH in Veterans

• Screen for and address comorbidities

– PTSD

– Depression

– Insomnia

• Refer to psychiatric services if indicated

• Identify/Address medication overuse

• Triptans for acute headache attacks

• Close follow-up to:

– Monitor therapeutic response

– Adjust therapy

• Provide education

Managing Persistent PTH in Veterans

• Screen for and address comorbidities

– PTSD

– Depression

– Insomnia

• Refer to psychiatric services if indicated

• Identify/Address medication overuse

• Triptans for acute headache attacks

• Close follow-up to:

– Monitor therapeutic response

– Adjust therapy

• Provide education

Discuss expectations

PTH Among Athletes

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Typical Recovery from Simple Concussion

McCrory P et al. Br J Sports Med. 2005;39:178–186.

80-90% of athletes will recover within 7-10 days of injury



80-90% of athletes will recover within 7-10 days of injuryV

clinically



80-90% of athletes will recover within 7-10 days of injuryV

clinically

What about neurophysiological recovery?

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Delay between neural and behaviorally assessed recovery after concussion

• Persistent, significantly increased activation

–2 minus 1 n-back contrast in DLPFC*

– Inferior parietal lobe

• No significant differences on standard memory tasks (vs controls)

Longitudinal fMRI study in concussed subjects

Dettwiler A et al. J Neurotrauma. 2014;31:180–188.

Functional brain activation differences persist at 2 months after injury in concussed athletes

*Bilateral dorsolateral prefrontal cortex

Two Big Questions. . .


1. How do we approach headache in the

acute/subacute stage of injury?

How do we approach the athlete with

persistent headache?

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1. How do we approach headache in the

acute/subacute stage of injury?

2. How do we approach the athlete with

persistent headache?

Headache in the Acute/Subacute Stage

“While symptomatic following an injury, it is important to emphasize to the athlete that physical AND cognitive rest is required.”

Dark closet effect

McCrory P et al. Br J Sports Med. 2009



Dark closet effect


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“Wait and pray” approach

Dark closet effect


Symptom-limited Physical and Cognitive Rest

The cornerstone of concussion management is symptom-limited physical and cognitive rest until the acute symptoms resolve and then a graded program

of exertion prior to medical clearance and RTP

Zurich Consensus Statement 2012


When to Start Exercise?

Previous best practice suggested waiting until athletes were asymptomatic

Symptom Reporting

Assessment method

(written vs oral)Social Factors/

Sport Culture

Comorbidities (anxiety,

depression, migraine)

PersonalityMotivation

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PTH ARS Question 1

Which of the following is true about postconcussive athletes?

A. They experience higher rates of anxiety and depression than the general population

B. Once asymptomatic, they can immediately return to competition

C. They should avoid physical and mental exertion during the acute stage of injury

D. All of the above

What Is Asymptomatic?

What percentage of non-injured people report concussion-like symptoms?


Iverson GL, Lange RT. Appl Neuropsychol. 2003;10:137–144.; McCrea M et al. JAMA. 2003;290:2556–2563.


36–76%Concussed and non-concussed athletes report

some degree of symptoms throughout the season

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Iverson GL, Lange RT. Appl Neuropsychol. 2003;10:137–144.; McCrea M et al. JAMA. 2003;290:2556–2563.


36–76%Concussed and non-concussed athletes report

some degree of symptoms throughout the season

Failure to achieve asymptomatic status does not necessarily mean incomplete recovery from concussion

Posttraumatic Headache cont.

Occurs in ≈94% of athletes with

sports-related concussion

Marar M et al. Am J Sports Med. 2012; 40:747–755.

Headache in the athlete is not uncommon.

Key Point

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Headache in the Athlete

2% of population have given up sports

participation due to primary exertional HA

30%

36%

36%

50%

Cephalalgia 2008; Br J Sports Med 1994; WV Med J 1999; Headache 2012; Cephalalgia 2002

Adolescents (13–15)

with Exertional HA

Cyclists

College Athletes

Distance Runners

Is Pre-existing Migraine a Risk Factor for Prolonged Recovery after Concussion?


Head (or neck) injuries can increase the severity

of headaches in pre-existing migraine1

1. Packard RC. J Head Trauma Rehabil. 1999;14:9–21.

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Head (or neck) injuries can increase the severity

of headaches in pre-existing migraine1

1. Packard RC. J Head Trauma Rehabil. 1999;14:9–21.; 2. Kutcher JS et al. Curr Sports Med Rep. 2010;9:16–20.

It is the experience of the authors that people who have migraines seem to

have more severe and prolonged concussion courses after injury2



38%

25%

21%

10%

6%



Tension-type Other



38%

25%

21%

10%

6%



Tension-type Other

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Posttraumatic Headache with Migraine Characteristics

Mihalik et al. Am J Sports Med. 2013;41:1490–1496.; 2. Kontos et al. Am J Sports Med. 2013;41:1497–1504; 3. Mihalik et al. J Neurosurg. 2005;102:850–855.

Posttraumatic migraine characteristics are related toprolonged symptom recovery1,2


Athletes with posttraumatic migraine characteristics experience greater deficits on neurocognitive testing3




Athletes with posttraumatic migraine characteristics experience greater deficits on neurocognitive testing3



Should we be treating more aggressively in the acute time

period post-injury?

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Treatment of Headache After mTBI


“Assertive, early treatment

[of headache after mTBI] may be warranted to avoid

chronicity and disability.”

Return to Play Considerations

Headache Type Return to Play?

Acute postconcussive headache: ???

Chronic postconcussive headache:

-With persistent concussive symptoms? ???

-In the absence of other concussive

symptoms????



Acute postconcussive headache: Contraindicated


-With persistent concussive symptoms? ???


symptoms????

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-With persistent concussive symptoms? Contraindicated


symptoms????

Chronic Headache After Head Trauma

Trauma to the head (or neck) may trigger the migraine process in an

individual who did not previously experience migraine headaches1

1. Speed WG, Solomon S. The Practicing Physician’s Approach to Headache, ed 4. 1986.

Chronic Headache After Head Trauma

Trauma to the head (or neck) may trigger the migraine process in an

individual who did not previously experience migraine headaches1

1. Speed WG, Solomon S. The Practicing Physician’s Approach to Headache, ed 4. 1986.; 2. Weiss HD, et al. Headache. 1991

31% of patients experiencing chronic headache after minor

head trauma reported a family history of migraine2

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symptoms????


*With directed treatment (and improvement) of underlying headache.






symptoms?Possible*

PTH ARS Question 2

In which of the following situations might an athlete be allowed to return to play?

A. Chronic postconcussive headache with persistent concussive symptoms

B. Acute postconcussive headache

C. Chronic postconcussive headache with no other concussive symptoms

D. None of the above

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Thank You!

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Post Traumatic Headache...2018/07/05 · Phenotype of Headache following TBI (N=378) 38% 25% 21%...

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